The patient is seven years old and was diagnosed with idiopathic toe walking by a pediatric neurologist at the age of five years old. The patient has been a toe walker since he began walking at the age of 12 months old. The patient was evaluated by a physical therapist at age of 5 who determined that all his gross motor milestones were normal. He can currently correct heel strike when given verbal cues, but quickly goes back to toe walking. The patient received intensive physical therapy two times a week for 12 weeks and was referred to an orthotist for bracing eight weeks into his treatment. He received bilateral hinged ankle-foot orthotics (AFOs). His parents were given a home program throughout his treatment to strengthen the bilateral anterior tibialis, improve his balance, and to complete passive stretching to the bilateral gastrocnemius (gastrocs) and hamstrings. He is an athletic child and plays football, rides dirt bikes and rides horses. He does still struggle with heel strike without his braces, but they tend to limit him in the activities he enjoys doing.
Upon recent physical therapy evaluation, the Physical Therapist found that the patient walks, runs and hops with little to no heel strike. He presents with tight heel chords, bilateral gastrocnemius and limited dorsiflexion. He displays weakness in the anterior tibialis and difficulty with squat-type activities and balance tasks, especially single leg stance. The patient has difficulty keeping up with his peers due to speed, coordination and strength in the lower extremities. He will need strengthening of the anterior compartment, intrinsic plantar muscles, and glute and abdominal musculature as well as stretching to the dorsiflexors and focus on balance activities to improve his functional mobility and stability.
Utilizing Clinical Practice Guidelines (CPGs)
According to the Clinical Practice Guidelines written by the Cincinnati Children’s Hospital Medical Center, Management of Idiopathic Toe Walking, one of the most common outcome measurements for idiopathic toe walking is the Observational Gait Scale. (Cincinnati Children’s Hospital Medical Center, 2011) This tool is used to determine the arthrokinematics of the foot, ankle and knee during gait. The therapist observes the child in both the frontal and sagittal planes to score each lower extremity separately. There are eight sections that are observed. The ‘perfect’ score on the test would be 22 points per lower extremity. The test focuses on gait changes over time and scores the following categories:
- knee position in midstance;
- initial foot contact;
- foot contact at midstance;
- timing of heel rise;
- hindfoot at midstance;
- base of support;
- gait assistive devices;
- change in gait since last observation (Alvarez et al., 2007)
The treatment approach with the highest potential of success would be to include stretching, strengthening, balance and weight bearing feedback activities. The patient will benefit from passive stretching progressed to active stretch activities, static balance and strengthening tasks progressing to dynamic, more advanced tasks and the treatment should include focus on improved weight bearing through the entire foot, paying close attention to weight bearing through the hindfoot to increase strength, proprioception, balance and stability.
To begin treatment, the child should receive stretching passively to the gastrocnemius and hamstrings bilaterally in seated or supine. Each stretch should be held for 10 seconds, five times, each leg progressing to a 20 second hold time when tolerated. The child should be progressed to active stretching tasks relatively quickly so that these tasks can be utilized in his home program. He is an active child so many of the progressions should occur quickly in respect to each treatment session. Activities that will promote active stretching may include static and dynamic tasks on the wedge board, dynadisc, and foam balance beam. The child may complete static stance on dynadisc while attempting to catch and toss bean bags with focus on maintaining weight through his hindfoot. Dynamically, the child can stand on a dynadisc with cones in a half circle in front of him while using one foot to tape each cone to promote strength, stabilization and active dorsiflexion and hamstring stretches to the stance lower extremity.
Further progression in active stretching will include tasks that require more coordination and strength. These tasks can include “animal walks” which include the crab crawl, bear walk, frog jump, and penguin walk. During the crab crawl the child maintains a bridge position, keeping his rear-end off the floor and propels forward and backward with hands and feet. When completing the bear walk the child will use his hands and feet to propel forward and backward in a prone-like stance keeping his knees from touching the floor. During the frog jump activity the patient will start in a deep squat, launch upward and forward simultaneously while therapist encourages him to complete each jump with full foot connection with the floor during take-off and landing. Finally, when completing the penguin walk, the child will pull his toes upward and walk only on the heels of his feet without his toes or midfoot touching the floor. These activities will promote lengthening of the gastrocs and hamstrings and help with balance as well as strength of the anterior tibialis, gastrocs, hamstrings, glutes and core. (DPT, 2019)
Strengthening and balance activities will be completed from the start of treatment. The child is active enough that he is already capable of advanced tasks, but when completing tasks in therapy he will be expected to complete isolated strengthening tasks to improve his balance and stability. He will need to strengthen the intrinsic plantar muscles of the feet which include the abductor hallucis, flexor digitorum brevis and abductor digiti minimi. These muscles will help to improve his overall balance. To strengthen these muscles, he can complete a marble pick-up with his toes while in seated and progress to utilizing dynamic surfaces, such as textured stepping stones or pillows, for a walk-over obstacle course.
The patient will need to strengthen the muscles of the anterior compartment as well. These muscles include the dorsiflexors and inverters of the ankle which are the anterior tibialis, extensor digitorum longus, extensor hallucis longus and the peroneus tertius. The child can complete bean bag walks to cue heel walking while holding bean bags on the dorsum of the foot. He can also complete scooter board play activities focusing on using his heels to propel the board forward. To progress further the child can work toward using hurdles to step or jump over to promote dorsiflexion and heel strike. Utilizing a visual aid on the floor, between hurdles, can help to cue heel strike as well. (DPT, 2019)
Strengthening the abdominal muscles and glutes is important for the child to be able to maintain proper posture and to improve his balance. Bridging is an exercise that can target multiple muscle groups including strengthening the quads, glutes and abdominal muscles while facilitating stretch to the gastrocs. The child would begin this exercise in hook-lying placing both feet flat on the surface and lifting hind-end from the table or floor. This exercise can be progressed by using a half bolster under the child’s feet to further promote dorsiflexion when lifting into bridge position.
The bolster swing is another useful tool in targeting multiple muscle groups with one activity. The child can straddle the swing while the therapist swings the child side-to-side and forward and backward. This activity activates the adductors, glutes and core musculature. When the child shows improved stability and strength, he can progress to bouncing on the swiss ball or sitting on the swiss ball while catching and throwing objects, to continue to work toward improved core and leg strength while increasing mobility in dorsiflexion and gastrocs.
Idiopathic toe walkers require tactile and pressure feedback activities to promote heel strike. Weight bearing activities can increase the child’s proprioception thus increasing his likelihood of completing heel strike in gait and functional activities. For this portion of the treatment program, the patient can begin with squats or sit-to-stands on wedged foam or multi-textured stationary surface while focusing on shifting his weight into his hind foot. Utilizing visual aids on the floor also helps to guide proper foot alignment. These types of activity can facilitate the ankle, knee, hip and trunk stabilizer strength and improve static balance as well improving gastroc mobility. The patient can progress to dynadisc, multi-level obstacles, and multi-textured dynamic stepping stones focusing on weight through the hindfoot with each heel strike. Having the patient climb up a sliding board can also promote improved dorsiflexion and anterior tibialis, quad, hamstring, glute and core strength. Continuing to work on strength, balance and proprioceptive activities while working on motor planning is especially important to help the child meet the level of coordination of his peers. Hopscotch is great task to complete all of these things in a playful setting. (DPT, 2019)
Utilizing the CPG
Clinical Practice Guidelines are created to maximize patient care efficiency through recommendations that have been supported through evidence-based review. The CPG gives a description on benefits and possible negative outcomes of a different treatment approaches. Understanding what the CPG is and utilizing the treatment approaches that have been proven to provide patients with the best treatment outcomes will increase patient satisfaction. When addressing and collaborating with the Physical Therapist or referring physician, the Physical Therapist Assistant can use the CPG as a basis of support in the reasoning of why they feel a certain treatment approach may be appropriate for their patient. The CPG can also give insight to creating new ideas when creating a treatment program for patients so that the treatment does not plateau prematurely. (APTA, 2019)